MAKE A GIFT - Instructions:

This is not an online form. Print this page out, complete the form, and mail this with your tax deductable donation to:

Development Department
St. Anthony Community Hospital
15 Maple Avenue
Warwick, NY 10990
Please accept my gift of: (  ) $_____ (  ) $100 (  ) $50 ( ) $35 ( ) $25 ( ) $15
Check made payable to St. Anthony Community Hospital
 

Title:(Mr / Mrs / Miss / Ms) ______

First Name:

________________________________

Last Name:

________________________________

Address:

________________________________

Town:

________________________________

State:

______         Zip Code:  ___________

If contributing by credit card:
Credit Card Type: (circle) MC , Visa
Credit Card Number:

 __  __  __  __  - __  __  __  __  - __ __ __ __ -  __  __  __  __

Expiration Date: Month ____ Year ____

Signature (required when donating by credit card)

_________________________________  Date: ____ / ____ / ____

I wish to make a gift ___ In honor of, or ___ in memory of:

Name: _______________________________  Occasion: _________________

Please send an acknowledgment card to:

Name:

________________________________

Address:

________________________________

Town:

________________________________

State:

______         Zip Code:  ___________

( The amount of the gift will not be mentioned unless you instruct us to. )

Please check this box ___ to receive further information on Wills, Trusts and Bequests
Please check this box ___ if your employer / company has a Matching Gift program and enclose your matching gift form.